We are committed to providing you with the best
possible medical care. If you have medical insurance, we will try to help you
receive your maximum allowable benefits. Please carefully read the following,
and complete the enclosed forms.
PAYMENT
FOR SERVICES is due at the time services are rendered or upon receipt of
patient billing statement. In order to expedite this payment we accept cash,
personal checks and accept MASTERCARD or VISA.
We will do our best to verify that we can treat you. This is
however, no guaranty of benefit. Any questions requiring your policy
deductibles and co-pay refer to your insurance company.
·
INSURANCE: For many of you, your insurance is a contract between
you and your employer or an insurance company, and we are not a party to that
contract. For some of you, we are under contract with your employer or
insurance company. For those patients whose plans list or accept Mitchell
Physical Therapy, Inc. as a contract provider, we will submit the appropriate
claim to your carrier. AFTER our office has received payment from your
insurance company and all appropriate adjustments have been made, YOUR
remaining balance will be billed to you and is then due and payable upon
receipt of the bill. Be advised our services may be Out of
Network for your policy, which could result in you having to meet an
additional deductible.
·
MEDICARE: For those patients who are covered by Medicare, we
will comply PATIENTS: with the law requiring physicians’ offices to
process insurance forms. AFTER our office has received payment from your
insurance company and all appropriate adjustment have been made, YOUR remaining
balance will be billed to you and is then due and payable upon receipt of
the bill.
·
WORK COMP: Mitchell Physical Therapy, Inc. will
submit the appropriate claim to your carrier. If your claim is denied you will
be responsible for the entire balance. Your bill in then due and payable
upon receipt.
·
AUTO CLAIMS: Mitchell Physical Therapy, Inc. will
submit the appropriate claim to your carrier. If your claim is denied you will
be responsible for the entire balance. If your PIP runs out or your claim goes
to litigation you will be responsible for the balance. We will not carry the
balance until your settlement, as we are not a party to your claim.
·
RETURNED CHECKS: There is a $25 fee for all returned checks.
·
PAYMENT PLANS: If you believe you will need a payment plan,
arrangements will need to be approved through our billing department PRIOR to
your balance exceeding $100 and are subject to approval.
·
BE ADVISED A $3.00
REBILL FEE WILL BE APPLIED TO DELAYED PAYMENTS
·
If questions arise,
please contact our billing department at 1-888-467-2425 for assistance. We
consider financial matters and protection of your medical information important
and ask you to bring any concerns to our attention
·
PROTECTION OF
PATIENT INFORMATION: Please
understand your patient information is held in confidences and that no
information will be given out without your direct consent. By signing this form
it gives us permission to use your information solely for the purpose of
collection of your claims. If information is requested by anyone or company
other than your insurance or yourself, you will need to provide us with a
release of information approval form. Copies of this policy are posted in the
clinic and are also available for your records.
Thank you for using Mitchell
Physical Therapy, Inc. for your care.
I have read and understand
this financial and privacy policy. Signature: Date: